Title: Financial Activities and Errors Among Patients with Dementia

Authors: Madhumitha Manivannan, Winston Chiong, MD PhD

Research Questions:
Descriptive/exploratory:
Investigate current financial activities of patients with dementia
For people with dementia, financial errors due to either their own mismanagement or to abuse by others can have devastating personal and family consequences. Studies show that financial mismanagement is often the earliest sign of cognitive decline, well before patients and their families are aware of reduced cognitive capacity. Furthermore, patients with dementia often continue to handle finances despite receiving a diagnosis of dementia, indicating high vulnerability to mismanagement and errors. One gap in the current literature is in characterizing the extent to which patients with dementia continue to engage in real-world activities, as a risk factor for financial mismanagement and abuse.

Do different dementia syndromes have characteristic types of financial errors?
Different dementia syndromes target specific neural systems that may be reflected in susceptibility to different types of error (e.g. amnestic errors in Alzheimer’s disease versus impulsive decisions in frontotemporal dementia). Understanding these differences might help providers better counsel and support patients with dementia and their families in mitigating risks associated with specific errors.

Hypotheses:
Primary Aim Hypotheses

Hypothesis a
Financial mistakes due to being too gullible or trusting and wasteful or too careless with money are more prevalent in patients with frontotemporal dementia than in patients with Alzheimer’s Disease.

Hypothesis b
Financial mistakes due to trouble with memory are more prevalent in patients with Alzheimer’s disease than in patients with frontotemporal dementia.

Secondary Aims (Exploratory)
-We will examine the prevalence of financial mistakes among patients with primary progressive aphasia due to the reasons listed in hypotheses a and b (above).

Sampling Plan

Existing Data:
The “parent” projects we are recruiting our participants from include the UCSF ADRC (Alzheimer’s Disease Research Center) and the UCSF Frontotemporal Dementia: Genes, Images, and Emotions program (funded by the Parent Project Grant [PPG]). Behavioral data have been collected on both a Qualtrics platform as well as paper versions of the financial activities questionnaire. Behavioral data has been reviewed to assess enrollment numbers in disease categories and tailor future recruitment strategies. At the time of this pre-registration, all data from bvFTD and PPA participants have been collected. We are continuing to enroll AD participants to reach our target enrollment numbers. No analyses have been conducted on collected data.

Data Collection Procedures:
Participants will be recruited from one of two “parent” projects, the ADRC or the PPG, with continuing clinical, neuropsychological and neuroimaging data collection. As part of enrollment in one of the two aforementioned projects, subjects undergo extensive neurological and neuropsychological evaluations, neuroimaging, and clinical interviews and will be diagnosed by a team of neurologists, neuropsychologists, and nurses using consensus research criteria for Alzheimer’s disease, bvFTD, and primary progressive aphasia. Inclusion criteria will mirror those in each of the three parent projects: subjects will be fluent in English and will not have a history of another cognitive or neurological disorder.
Questionnaires are completed by participants' family caregivers, who are co-enrolled in longitudinal research with patients as informants. Initially, some questionnaires were distributed to caregivers as paper copies; later, these questionnaires were transferred to Qualtrics. Caregivers were provided with tablet computers during patients' in-person visits and guided to answer the questionnaire. For some caregivers, if collection could not be accomplished during the in-person visit, then the Qualtrics instrument was e-mailed for completion at home.

Sample Size:
Our target sample size is 150. We plan to enroll 50 patients with frontotemporal dementia, 50 patients with Alzheimer’s Disease, and 50 patients with primary progressive aphasia.

Sample Size Rationale:
Chiong et al.’s study (2014) of differences in financial decision-making among patients with Alzheimer’s Disease and frontotemporal dementia reported moderate effect sizes for a dissociation between cognitive versus affective aspects of decision-making4.

Hypothesis a:
Applying standard power calculations based upon effect sizes observed in Chiong et al. (2014), two-sided alpha = 0.05 level tests based on 50 subjects in each group will have 43% power to detect observed differences in errors reflecting interpersonal solicitation, 93% power to detect observed differences in errors reflecting excessive spending, and 99% power to detect observed differences in errors reflecting decreased sensitivity to losses. As question 9 and 10 relate to all three of these factors, we expect the power of our combined item to fall somewhere between the above values.

Hypothesis b:
Applying standard power calculations based upon effect sizes observed in Chiong et al. (2014), two-sided alpha = .05 level tests based on 50 subjects in each group will have 88% power to detect observed differences in errors reflecting memory.

Variables
Measured Variables:
Financial Activities Questionnaire
In this questionnaire, caregivers of patients with dementia answer questions related to the patient’s current financial activities, past financial errors, and different types of financial errors. Questions 1-6 ask about the kinds of financial decision-making the patient participated in both before and after they had problems with memory or cognition. Question 7 allows respondents to elaborate on their answers to 1-6.
Questions 8-13 ask about the types of financial errors the patient has made in the past year, e.g. mistakes due to memory problems, being too trusting, or worrying too much. Question 14 allows respondents to elaborate on their answers to 8-13. All multiple choice questions have answer choices of ‘Yes,’ ‘No,’ or ‘I did not know them well enough to answer.’

Analysis plan:
For our primary aims, we will run multiple logistic regression with respondents' answers to question 9 and 10 (mistakes due to being too trusting/gullible, and mistakes due to wasteful or careless with money, respectively) as outcome variables for hypothesis a and using question 11 (mistakes due to impaired memory) as the outcome variable for hypothesis b. The model will include predictors for patient’s age, gender, and educational attainment as demographic variables.

References:

Pérès, K., Helmer, C., Amieva, H., Orgogozo, J. M., Rouch, I., Dartigues, J. F., &
Barberger-Gateau, P. (2008). Natural history of decline in instrumental activities of daily living performance over the 10 years preceding the clinical diagnosis of dementia: a prospective population-based study. Journal of the American Geriatrics Society, 56(1), 37–44. https://doi.org/10.1111/j.1532-5415.2007.01499.x

Triebel, K. L., Martin, R. C., Nabors, L. B., & Marson, D. C. (2009). Medical decision-making capacity in patients with malignant glioma. Neurology, 73(24), 2086-2092.

Widera, E., Steenpass, V., Marson, D., & Sudore, R. (2011). Finances in the older patient with cognitive impairment:“He didn't want me to take over”. Jama, 305(7), 698-706.

Chiong, W., Hsu, M., Wudka, D., Miller, B. L., & Rosen, H. J. (2014). Financial errors in dementia: testing a neuroeconomic conceptual framework. Neurocase, 20(4), 389-396.

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